Decompressive craniectomy for patients with malignant infarction of the middle cerebral artery: A pooled analysis of
Xiaojun Luo1, Bo Yang2, Junjie Yuan3
1Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China.
Insights
Decompressive craniectomy (DC) significantly reduces mortality in patients with malignant middle cerebral artery infarction undergoing endovascular therapy. However, most survivors experience moderate to severe disability, highlighting the need for improved quality of life interventions.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Decompressive craniectomy (DC) is known to reduce mortality in massive cerebral infarction.
- Its effectiveness in the context of endovascular therapy for malignant middle cerebral artery (MCA) infarction remains unclear.
- This study investigates DC's role in patients receiving endovascular treatment.
Purpose of the Study:
- To evaluate the efficacy of decompressive craniectomy (DC) in reducing mortality and improving outcomes for patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy.
- To assess the impact of DC on disability and quality of life in this patient population.
Main Methods:
- Pooled data from the DEVT and RESCUE BT trials involving patients with malignant MCA infarction and herniation.
- Patients were stratified into DC and conservative treatment groups.
- Primary outcome: 90-day mortality. Secondary outcomes: 90-day modified Rankin Scale (mRS) scores and quality-of-life scores.
- Multivariable logistic regression was used to analyze associations between DC and clinical outcomes.
Main Results:
- Mortality at 90 days was significantly lower in the DC group (59.5%) compared to the conservative group (85.2%) (adjusted OR, 0.31; P=0.04).
- A higher proportion of patients in the DC group experienced moderate to severe disability (mRS 4 or 5) compared to the conservative group (21.6% vs 6.6% for mRS 4; 10.8% vs 4.9% for mRS 5).
- Quality-of-life scores were initially higher in the DC group, but this association was not significant in multivariable analyses.
Conclusions:
- Decompressive craniectomy (DC) is associated with reduced mortality in malignant MCA infarction patients undergoing endovascular therapy.
- Despite improved survival, the majority of survivors face moderate to severe disability.
- Further interventions are needed to enhance the quality of life for these patients.
Background:
Decompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy.
Methods:
We pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression.
Results:
Of 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted β Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75).
Conclusions:
DC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life.
Clinical Trial Registration:
The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.
